Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1127_Библиотеки_им_академика_М_И_Перельмана
.pdf
SECTION 2 Current Clinical Applications and Techniques
https://t.me/med1917
patients, 11 of whom had cholecystitis. Two major complications (one stroke and one trocar herniation) and thirteen
minor complications were reported (12.7%). Among the
gynecologic complications, infection and dehiscence of the
colpotomy closure were reported.
Discussion
Currently, transvaginal access is the preferred approach in
humans because this route obviates the risk of intestinal
content leakage via an imperfectly closed access site. Almost
all reported procedures use some form of transparietal assistance for exposure of the gallbladder, application of laparoscopic clips to seal the cystic duct, and assistance in
visualization and dissection. The postoperative outcome is
favorable in most of studies. Reported mortality rate is 0%.
Biliary leaks were reported in four studies and treated successfully by laparoscopic or endoscopic drainage and stenting. Few gynecologic complications were reported. No
clinical randomized trial comparing NOTES and laparoscopic
cholecystectomy has ever been published. Results of multicenter trials have been recently published. In the Germany
NOTES registry, the analysis was based on an anonymous
and voluntary registry, having its inherent advantages and
limitations [22]. In an update of the registry (oral presentation 2010 Digestive Disease Week), Lehmann presented
results on 1328 patients at 87 hospitals participating in the
registry between March 2008 and September 2010. All but
10 of the patients in the registry were women. A transvaginal approach was used in 1310 of the operations, transgastric in 4, transrectal in 9, and another approach in 1. There
were 26 conversions to laparoscopy and 12 to laparotomy.
There were 22 intraoperative complications (1.6%), 34 postoperative ones (2.5%), and no deaths so far. The two major
intraoperative complications were a rectal injury requiring
a Hartmann procedure later and a small bowel injury necessitating segment resection. In addition to minor complications in the postoperative period, there were two laparoscopies
for pain (without pathological fi ndings) and one laparoscopic drainage for an abscess in the pouch of Douglas. No
biliary injury was reported. In an International Multicenter
Trial reported by Zorron et al. [9], the intraoperative complication rate of transvaginal cholecystectomy (240 patients)
was 6.6%, postoperative complications were observed in
8.1%. Bleeding from the cystic artery (fi ve patients), gastric
and bowel injury (two patients), and vaginal laceration
(three patients) were successfully managed intraoperatively.
Biliary leak was observed in two patients, and was managed
by nasobiliary and percutaneous drainage in one patient and
laparoscopic re -operation in the other. These large reports
demonstrate that transvaginal NOTES cholecystectomy can
be performed safely.
Experience has shown that the use of a new access to
perform a surgical procedure induces new complications.
This was observed when laparoscopy was introduced, with
the description of visceral and vascular injuries associated
with the use of trocars. Given the low rate of access complications, the transvaginal route compares favorably with
laparoscopic access. The reported rate of procedure -related
complications is also very low. Major bile tract injury has
never been reported but we must bear in mind that the
majority of operations were performed in selected patients,
by dedicated teams under control of strict IRB protocols.
With appropriate training, experience, and patient selection,
the use of a hybrid transvaginal technique seems feasible
and applicable to routine clinical use.
The major concern with the transgastric procedures is the
safety of creation and closure of the gastrotomy. Laparoscopic surveillance is used by few teams having limited
experience. Liberal use of additional laparoscopic trocars is
mandatory to overcome problems that are encountered at
all steps of the procedure: access, retraction of the gallbladder, dissection, clipping, and closure of the gastrotomy. An
additional challenge is to obtain adequate spatial orientation
with the endoscope in a retrofl exed position when the image
is upside down and off -axis manipulation is required.
Although some of this spatial incongruity is likely to be
overcome with experience, exposure, interpretation of the
anatomy, and identifi cation of the structural landmarks
proved demanding [24]. The access -related complication
rate is low, given that gastrotomy is performed under laparoscopic surveillance. However, bleeding from epiploic vessels
needed conversion to open surgery in one patient [9]. Bile
leak was reported in 2 of 29 patients [9]. The experience
reported in the literature is very limited and no conclusion
can be drawn. TGC epitomizes the inadequacy of the current
fl exible endoscope and instruments for performing NOTES
procedures and must be considered very cautiously.
Conclusions
Currently, most cholecystectomies in the developed world
are performed laparoscopically with excellent results; the
bar has thus been set very high. The future of NOTES cholecystectomy lies not only in the development of adequate
technologies but also in the patient ’s perception of the
potential advantages and risks of such an innovative
approach. Both parameters are strongly linked, as there is
no future for a technique that would be used in a minority
of patients. Although NOTES is still evolving, studies demonstrate that a majority of patients perceive NOTES favorably as a potential technique for a cholecystectomy. This
preference for NOTES diminished remarkably if the complication rates were greater than that for a laparoscopic cholecystectomy [25,26]. Procedure -related risks, pain, and
124
CHAPTER 11 NOTES Cholecystectomy
https://t.me/med1917
recovery time were more important than cosmesis, cost,
length of hospital stay, and anesthesia type in the choice.
Attempts at reducing cholecystectomy -associated morbidity
and improving cosmesis are valuable and will drive the
development of novel surgical instrumentation.
Chapter video clips
Video 11.1 Transgastric access to the peritoneal cavity.
Video 11.2 Transgastric cholecystectomy.
Video 11.3 Transvaginal cholecystectomy.
References
1 Gallstones and Laparoscopic Cholecystectomy . National Insti-
tutes of Health Consensus Development Conference . National
Institutes of Health. 1992;10:1–28.
2 Kalloo AN, Singh VK, Jagannath SB, et al. Flexible transgastric
peritoneoscopy: a novel approach to diagnostic and therapeutic
interventions in the peritoneal cavity . Gastrointest Endosc
2004;60(1):114–17.
3 Santos B, Auyang E, Hungness E, et al. Preoperative ultrasound
measurements predict the feasibility of gallbladder extraction
during transgastric natural orifi ce translumenal endoscopic
surgery cholecystectomy . Surg Endosc 2011;25(4): 1168–75.
4 Rattner D, Kalloo A. ASGE/SAGES Working Group on Natural
Orifi ce Translumenal Endoscopic Surgery. October 2005 . Surg
Endosc 2006;20(2):329–33.
5 Dallemagne B, Perretta S, Allemann P, et al. Transgastric chole-
cystectomy: from the laboratory to clinical implementation .
World J Gastrointest Surg 2010;27:187–92.
6 Dallemagne B, Perretta S, Allemann P, et al. Transgastric hybrid
cholecystectomy . Br J Surg 2009;96(10):1162–6.
7 Salinas G, Saavedra L, Agurto H, et al. Early experience in
human hybrid transgastric and transvaginal endoscopic cholecystectomy . Surg Endosc 2010;24(5):1092–8.
8 Horgan S, Thompson K, Talamini M, et al. Clinical experience
with a multifunctional, fl exible surgery system for endolumenal,
single-port, and NOTES procedures . Surg Endosc 2011;25:
586–92.
9 Zorron R, Palanivelu C, Galvao Neto MP , et al. International
Multicenter Trial on Clinical Natural Orifi ce Surgery – NOTES
IMTN study: preliminary results of 362 patients . Surg Innov
2010;17(2):142–58.
10 Auyang ED, Hungness ES, Vaziri K, et al. Human NOTES chole-
cystectomy: transgastric hybrid technique . J Gastrointest Surg
2009;13(6):1149–50.
11 Marescaux J, Dallemagne B, Perretta S, et al. Surgery without
scars: report of transluminal cholecystectomy in a human being .
Arch Surg 2007;142(9):823–6; discussion 826 –7.
12 Bessler M, Stevens PD, Milone L, et al. Transvaginal laparoscopi-
cally assisted endoscopic cholecystectomy: a hybrid approach to
natural orifi ce surgery . Gastrointest Endosc 2007;66(6):1243–5.
13 Bessler M, Gumbs A, Milone L, et al. Pure natural orifi ce trans-
luminal endoscopic surgery (NOTES) cholecystectomy . Surg
Endosc 2010;24: 2316–17.
14 Davila F, Tsin DA, Dominguez G, et al. Transvaginal cholecys-
tectomy without abdominal ports . JSLS 2009;13(2):213–16.
15 de Sousa LH, de Sousa JA, de Sousa Filho LH, et al. Totally
NOTES (T -NOTES) transvaginal cholecystectomy using two
endoscopes: preliminary report . Surg Endosc 2009;23(11):2550–
55.
16 Asakuma M, Perretta S, Allemann P, et al. Challenges and
lessons learned from NOTES cholecystectomy initial experience:
a stepwise approach from the laboratory to clinical application .
J Hepatobiliary Pancreat Surg 2009;16(3):249–54.
17 Horgan S, Mintz Y, Jacobsen G, et al. Magnetic retraction for
NOTES transvaginal cholecystectomy . Surg Endosc 2010;24:2322.
18 Navarra G, Rando L, La Malfa G, et al. Hybrid transvaginal
cholecystectomy: a novel approach . Am J Surg 2009;197(6):
e69–72.
19 Zornig C, Emmermann A, von Waldenfels HA, Mofi d H. Laparo-
scopic cholecystectomy without visible scar: combined transvaginal and transumbilical approach . Endoscopy 2007;39(10):
913–15.
20 Gumbs AA, Fowler D, Milone L, et al. Transvaginal natural
orifi ce translumenal endoscopic surgery cholecystectomy: early
evolution of the technique . Ann Surg 2009;249(6):908–12.
21 Zornig C, Siemssen L, Emmermann A, et al. NOTES cholecys-
tectomy: matched -pair analysis comparing the transvaginal
hybrid and conventional laparoscopic techniques in a series of
216 patients . Surg Endosc 2011;25(6):1822–6.
22 Lehmann KS, Ritz Jr P , Wibmer A, et al. The German Registry
for Natural Orifi ce Translumenal Endoscopic Surgery: report of
the fi rst 551 patients . Ann Surg 2010;252(2):263–270.
23 Linke GR, Tarantino I, Hoetzel R, et al. Transvaginal rigid -hybrid
NOTES cholecystectomy: evaluation in routine clinical practice .
Endoscopy 2010;42(7):571–5.
24 Perretta S, Dallemagne B, Donatelli G, et al. The fear of trans-
gastric cholecystectomy: misinterpretation of the biliary
anatomy . Surg Endosc 2011;25(2):648.
25 Varadarajulu S, Tamhane A, Drelichman ER. Patient perception
of natural orifi ce transluminal endoscopic surgery as a technique
for cholecystectomy . Gastrointest Endosc 2008;67(6):854–60.
26 Swanstrom LL, Volckmann E, Hungness E, Soper NJ. Patient
attitudes and expectations regarding natural orifi ce translumenal endoscopic surgery . Surg Endosc 2009;23(7):1519–25.
27 Niu J, Song W, Yan M, et al. Transvaginal laparoscopically
assisted endoscopic cholecystectomy: preliminary clinical results
for a series of 43 cases in China . Surg Endosc 2011;25(4):
1281–6.
28 Pugliese R, Forgione A, Sansonna F, et al. Hybrid NOTES trans-
vaginal cholecystectomy: operative and long -term results after
18 cases . Langenbecks Arch Surg 2010;395(3):241–5.
29 Decarli LA, Zorron R, Branco A, et al. New hybrid approach for
NOTES transvaginal cholecystectomy: preliminary clinical experience. Surg Innov 2009;16(2):181–6.
30 Horgan S, Cullen JP , Talamini MA, et al. Natural orifi ce surgery:
initial clinical experience . Surg Endosc 2009;23(7):1512–18.
31 Palanivelu C, Rajan PS, Rangarajan M, et al. NOTES: Transvagi-
nal endoscopic cholecystectomy in humans -preliminary report
of a case series . Am J Gastroenterol 2009;104(4):843–7.
32 Noguera J, Dolz C, Cuadrado A, et al. Hybrid transvaginal chole-
cystectomy, NOTES, and minilaparoscopy: analysis of a prospective clinical series . Surg Endosc 2009;23(4):876–81.
125
SECTION 2 Current Clinical Applications and Techniques
https://t.me/med1917
33 Kilian M, Raue W, Menenakos C, et al. Transvaginal -hybrid vs.
single-port-access vs. “conventional” laparoscopic cholecystectomy: a prospective observational study . Langenbecks Arch Surg
2011;396(5):709–15.
34 Hensel M, Schernikau U, Schmidt A, Arlt G. Surgical outcome
and midterm follow -up after transvaginal notes hybrid cholecystectomy: analysis of a prospective clinical series . J Laparoen-
dosc Adv Surg Tech A 2011;21(2):101–6.
35 Federlein M, Borchert D, Müller V, et al. Transvaginal video -
assisted cholecystectomy in clinical practice . Surg Endosc
2010;24(10):2444–52.
36 Ramos AC, Murakami A, Galvao Neto M, et al. NOTES trans-
vaginal video -assisted cholecystectomy: fi rst series . Endoscopy
2008;40(7):572–5.
37 Cuadrado-Garcia A, Noguera J, Olea-Martinez J, et al. Hybrid
natural orifi ce transluminal endoscopic cholecystectomy: prospective human series . Surg Endosc 2011;25:19–22.
126
12
https://t.me/med1917
NOTES Appendectomy
Jörn Bernhardt , Holger Steffen , Sylke Schneider -Koriath, & Kaja Ludwig
Klinikum Suedstadt, Rostock, Germany
Introduction
Developments in surgical medicine during the late twentieth
and early twenty -fi rst century are characterized by a constant reduction in the invasiveness of surgery while upholding operative standards. In certain procedures, such as
cholecystectomy and appendectomy, open surgery has generally been superseded by laparascopic surgery. With other
surgical procedures, such as colon resection, a large proportion of operations are performed laparoscopically.
In the case of other medical conditions, such as the treatment of complications arising with acute and chronic pancreatitis, there has been a shift away from open surgery to
interventional endoscopic and sonographic procedures.
After the fi rst reports concerning the accessing of the
abdominal cavity via an external orifi ce and thence via an
internal organ [1], natural orifi ce translumenal endoscopic
surgery (NOTES) as a new surgical method involving
the introduction of fl exible endoscopes into the abdominal
cavity was initially used in animal experiments. Now that
the move away from open surgery and toward the minimally invasive technique of laparoscopic surgery has taken
place, endoscopic translumenal surgery represents the next
stage in this cascade, with the need for abdominal incision
being completely eliminated [2]. The anticipated benefi ts are
a reduction in postoperative wound pain, shorter convalescence, avoidance of wound infections and abdominal wall
hernias, as well as the absence of scars [3–5]. In this technique, the desired organ is accessed via a natural orifi ce.
In the operative treatment of acute appendicitis, laparoscopic surgery can be regarded as the standard procedure
[6]. However, the process of transition from open to laparoscopic surgery has taken considerably longer than in the case
of cholecystectomy. In addition to the cosmetic effect, which
is not particularly emphasized, the advantages of the laparascopic procedure are listed as shorter stays in hospital and a
lower rate of wound infection [7,8]. A higher rate of postoperative intra -abdominal abscesses, which has occurred in
isolated cases, cannot be generalized; it is dependent on
primary peritoneal contamination [7,9]. Particularly in the
analysis of subgroups such as overweight patients and atypical positions of the appendix, laparoscopic surgery has led
to a shortening of operating times and hospital stays, and,
in the case of the fi rst group of patients, to a signifi cant
reduction in the wound infection rate [10]. Initially
expressed fears that the predominance of the laparoscopic
appendectomy procedure would lead to the loss of a training
operation have not been borne out [6,11].
With the introduction of NOTES techniques to appendectomy as a further step in reducing invasiveness, the said
problems will have to be re -evaluated, but not until these
technologies have fully matured and can be extensively
employed. It is inevitable that, until the technique is fully
developed, a basic operation will be in the hands of just a
few specialists, but any new procedure can only become
established if it can be employed on a broad scale.
Techniques of NOTES appendectomy
Initial historical and gynecologic appendectomies
Long before the inauguration of the term “NOTES” there
were sporadic reports in the gynecologic literature concerning transvaginal resection of the appendix, always in connection with transvaginal gynecologic surgery.
The fi rst report of transvaginal appendectomies was published by Bueno in 1949 after performing the surgery on
three patients [12]. These operations were performed during
and after vaginal hysterectomy and extirpation of the
Natural Orifi ce Translumenal Endoscopic Surgery (NOTES): Textbook and Video Atlas, First Edition. Edited by Anthony N. Kalloo, Jacques Marescaux,
Ricardo Zorron.
© 2012 John Wiley & Sons, Ltd. Published 2012 by John Wiley & Sons, Ltd.
127
SECTION 2 Current Clinical Applications and Techniques
https://t.me/med1917
adnexa. In all cases, exposure of the appendix was only possible after displacement of the intestines. The operations and
patients’ postoperative progress were free of complications.
The fi rst series of ten transvaginal appendectomies was
reported by McGowan in 1966 [13]. The operations were
performed between 1958 and 1964. In two cases only a
posterior colpotomy was performed to provide access; in the
other cases the procedure was conducted following a hysterectomy. The treatment was carried out in the conventional manner. All the appendectomies were prophylactic in
character.
In 1975 Massoudnia reported 225 incidental appendectomies performed in connection with 2200 vaginal operations,
hysterectomies, and colpotomies performed for other
purposes [14]. The operating time was extended by an
average of 15 minutes as a result of the appendectomy; no
appendectomy-related complications occurred. A majority
of the patients who had undergone colpotomy and appendectomy were discharged on the third day after surgery; the
average hospital stay of all patients was eight days.
In connection with laparoscopically assisted hysterectomies, Pelosi and Pelosi report on 12 cases of vaginal incidental appendectomy [15]. Preparatory laparoscopic exploration
was regarded as useful for evaluating the mobility of the
cecum and the appendix.
In the past, the procedure involved pulling the cecum into
the vaginal cavity in order to remove the appendix.
The fi rst culdolaparoscopic appendectomies on three
patients were reported by Tsin et al. in 2001 [16]. Prior to
the transvaginal positioning of a 12 mm trocar, mini laparoscopy was performed and 5 mm and 3 mm trocars
positioned in the left and right lower abdomen. The vaginal
trocar was used for positioning the stapler and for extracting
the appendix.
Netzhat et al. removed the appendixes of 42 patients
by means of a transvaginally positioned stapler following
laparoscopic or laparoscopically assisted vaginal hysterectomy. Recovery was also conducted transvaginally. In
the histology of incidental appendectomies, endometriosis
lesions were discovered in four cases and a carcinoid tumor
in one case [17].
NOTES-related procedures
The difference between NOTES surgery and the operations
described previously is, for one thing, that the translumenal
path is the main route of access to the organ and that fl exible
endoscopes are primarily used. Furthermore, the indication
for surgery is the necessity of removing the acutely infl amed
appendix. The currently possible translumenal access routes
are the oral route, and thence through the gastric wall, and
the transvaginal route. In principle, the transrectal route
would also be possible, but on account of the major risk of
infection, there is as yet no clinical experience in respect of
that route. Since the transvaginal access route was the
easiest, the fi rst operations took place via that route.
Transvaginal appendectomy
Historically, the transvaginal route is not new, but the focus
on the effector organs, and the instruments employed, have
changed. This access route has long been tested in gynecology and safe decontamination is possible.
Various modifi cations of the procedure are possible in the
performance of transvaginal appendectomy: pure NOTES
surgery, fl exible hybrid surgery, i.e., with auxiliary abdominal access via the umbilicus, and surgery using rigid instruments inserted into the vagina, which is also a hybrid
technique. The fl exible hybrid technique can be divided into
two sub -types: laparoscopically supported fl exible appendectomy and fl exibly assisted rigid preparation. For all operations using a fl exible instrument, the use of a dual -channel
device with a separate water jet channel is to be recommended. This has the advantage that when one working
channel is in use, the other is available for suction, and the
irrigation channel is completely separate. For pure NOTES
procedures, the availability of CO
insuffl ation via one of the
2
working channels must also be ensured. In all cases, the
Lloyd-Davis position was employed, with the surgeon standing between the patient ’s legs. Also, in all the procedures,
the vaginal incision was closed in the same way, namely by
means of hand -sewn stitches. In the following, the technical
procedures used in the individual variants are presented.
Pure NOTES appendectomy (Video 12.1)
This procedure corresponds to the original NOTES concept,
but it is also the most diffi cult to perform, and with the currently available instruments it is only possible in exceptional
cases.
The abdominal cavity can be accessed via an open colpotomy, and it is conceivable that hydroscopic access after
Watrelot et al. might also be possible [18]. In this procedure,
NaCl solution is applied into the Douglas pouch by means
of a transvaginal puncture in order to form an organ -free
space by causing any loops in the small intestine to fl oat and
thus to increase distance from the rectum. With the patient
in the Trendelenburg position, a trocar is then introduced
and after removal of the fl uid capnoperitoneum is induced.
After the colpotomy incision has been made and the
endoscope inserted into the abdominal cavity, the capnoperitoneum is initially established via a working channel.
After the performance of a peritoneoscopy, the cecum is
located and the appendix exposed and pulled forward using
graspers (Figures 12.1 and 12.2). Now coagulation forceps
can be used, starting with initial fenestration, to prepare the
mesoappendix, starting from the base of the appendix. The
arteria appendicularis is coagulated or sealed with surgical
clips (Figures 12.3–12.6). Thanks to the high optical resolu-
128
CHAPTER 12 NOTES Appendectomy
https://t.me/med1917
Figure 12.1 Endoscopic view to the appendix after peritoneoscopy. Figure 12.2 Elevation of the appendix with an endoscopic grasper.
Figure 12.3 View to the arteria appendicularis in preparing the
mesoappendix.
tion, this procedure can be performed very precisely. Preparation can be facilitated by harnessing the appendix with a
second set of graspers. This, however, is not easy, because
both instruments project from the endoscope, are located
very close together and move simultaneously as the device
is manipulated. A further limiting factor is the reduced
maneuverability of the fl exible instruments, particularly in
cases of severe infl ammation and adhesion of the mesoap-
Figure 12.4 Coagulation of the arteria appendicularis.
pendix. Special needle -knives used in submucosal dissection
can also be employed for preparation (Figure 12.7). After
the base of the appendix has been exposed, ligation is performed using an endoloop and the appendix detached with
scissors, the snare, or the needle -knife (Figures 12.8–12.11).
The detached appendix can be recovered transvaginally
as the instruments are withdrawn (Figure 12.12). This
procedure is, however, only possible with low levels of
129
SECTION 2 Current Clinical Applications and Techniques
https://t.me/med1917
Figure 12.5 Fenestration of the mesoappendix.
Figure 12.6 Enlarging the fenestration.
Figure 12.7 Cutting of the mesoappendix with an insulation -tipped (IT)
knife.
infl ammation or in interval appendectomies, and cannot yet
be universally recommended.
Flexible hybrid NOTES appendectomy, assisted by
rigid instruments (Video 12.2)
In this procedure, the capnoperitoneum is established via a
Veress needle into the umbilicus and a 5 mm optical port
130
Figure 12.8 Placement of an endoloop at the base of the appendix.
introduced. After inspection of the abdomen, the posterior
vaginal vault is penetrated with the mandrin of a 12 mm
trocar with the patient in anti -Trendelenburg position. The
endoscope is then introduced via this opening and visualization is thereafter provided by this instrument. The appendix
can then be pulled free and tensioned by 5 mm graspers
introduced via the umbilical port (Figure 12.13). The prepa-
CHAPTER 12 NOTES Appendectomy
https://t.me/med1917
Figure 12.9 Closed endoloop.
Figure 12.11 Base of the appendix.
ration of the mesoappendix is conducted as described above
(Figure 12.14–12.18). Subsequently, the base of the appendix is ligated using a snare introduced via the umbilicus and
the appendix detached by means of laparoscopic scissors
(Figures 12.19 and 12.20). In these two procedures endoscopic graspers are used to tension the appendix. The specimen is then recovered transvaginally.
Figure 12.10 Cutting of the appendix with scissors between
endoloops.
Figure 12.12 Extracted appendix.
Rigid transvaginal appendectomy, assisted by
fl exible instruments (Video 12.3)
In this type of operation, a 12 mm trocar is introduced parallel to the endoscope in addition to the procedure described
above (Figure 12.21). Preparation can be conducted through
this using a rigid instrument and the detachment of the
appendix performed with a stapler. Here, the endoscope is
only used for visualization, irrigation, and suction and for
occasional grasping maneuvers (Figures 12.22–12.26). This
approach is particularly to be recommended in cases of
severe infl ammation and diffi culty in ligating the base of the
appendix.
131
SECTION 2 Current Clinical Applications and Techniques
https://t.me/med1917
Figure 12.13 Endoscopic view to the elevated appendix by a
laparoscopic grasper (some blood was running down from the trocar
insertion place at the umbilicus).
Figure 12.15 Fenestration of the mesoappendix.
Figure 12.14 Base-near endoscopic preparation of the mesoappendix.
Figure 12.16 Enlarging the fenestration and subsequently cutting of
the mesosigma.
Rigid transvaginal appendectomy
In contrast to the procedure described above, the endoscope
is here replaced by a rigid laparoscopic camera and the
operation performed using only laparoscopic instruments as
in culdolaparoscopy.
The fi rst transvaginal appendectomy was performed by
our working group as a pure NOTES procedure in September 2007 [19]. The patient was a 28 -year old woman with
recurrent sub -acute appendix irritation. Peri -operative pro-
132
phylactic antibiotics were administered and after local disinfection and the laying of a urine catheter, a conventional
posterior colpotomy was performed, via which a single channel gastroscope (Olympus Germany GmbH, Hamburg,
Germany) was then introduced into the abdominal cavity.
Insuffl ation with CO
at a pressure of 10 mm Hg was pro-
2
vided using an adapter through the working channel by
means of a laparoscopic insuffl ator (Karl Storz GmbH, Tuttlingen, Germany). The relevance of pressure monitoring
Figure 12.17 Subtle preparation of the appendix base.
https://t.me/med1917
CHAPTER 12 NOTES Appendectomy
Figure 12.18 Elevation of the prepared appendix with an endoscopic
grasper in expectation of the laparoscopic loop.
Figure 12.19 Placement of the laparoscopic loop.
has been demonstrated in several studies [20–22]. Preparation was conducted using hot biopsy graspers and an IT
knife. Between endoloops the appendix was detached using
endoscopic scissors. The patient was discharged on the third
postoperative day. Two weeks after surgery she began a successful two -handed Atlantic crossing in a sailing yacht.
Between October 2007 and February 2011, eleven
further patients gave their consent to hybrid surgery under
study conditions [23]. The operations were performed
according to the hybrid procedure described above, using a
dual-channel gastroscope (Karl Storz GmbH, Tuttlingen,
Germany). The sterility of the gastroscope was achieved by
Figure 12.20 Cutting of the appendix with laparoscopic scissors.
means of formaldehyde gas sterilization. In one case transvaginal access was not possible owing to extensive adhesions
in the lower abdomen. The mean operating time was
75.5 min, with a range of 40 –110 min. The intra -abdominal
pressure build -up amounted to 10 –12 mm Hg. The age of
the patients extended from 19 to 73 years. The BMI ranged
from 21.05 to 31.1. All procedures were conducted with the
administration of peri -operative prophylactic antibiotics. In
133
Соседние файлы в папке Библиотека им академика М.И. Перельмана